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Self-Report of Cancer Behaviors

Over the past 50 years, cancer research has emphasized individual behaviors (e.g., early detection screening, smoking, alcohol use, diet and nutrition, and physical activity) as important foci for prevention (Hataway & Bragg, 1984xClose
Hataway, J., & Bragg, C. (1984). Cancer: What is prevention? Family & Community Health, 7(1), 59-71.). Self-report instruments are among the primary methods of assessing cancer-related variables, including early detection screening and behavioral risk factors (primary prevention), as well as psychosocial risk factors (secondary and tertiary prevention). This section discusses self-reported cancer screening and considerations for the use of self-reported behavior and psychosocial risk factors, and concludes with suggestions about how to most effectively use and interpret self-report data.

Self-reported cancer screening. Cancer screening is a commonly reported clinical assessment designed to facilitate early detection, and regular screening is important for reducing morbidity and mortality across an array of cancer types. Although more objective alternatives exist for determining screening practices in the population (e.g., health insurance or medical records), self-report of screening is nonetheless the measure of choice in the majority of studies. For example, about two-thirds of research examining Pap smear testing utilized self-report methods (Newell, Girgis, Sanson-Fisher, Savolainen, & Hons, 1999xClose
Newell, S.A., Girgis, A., Sanson-Fisher, R., & Savolainen, N.J. (1999). The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: A critical review. American Journal of Preventive Medicine, 17(3), 211-229.).

With the growing emphasis on preventive care, a body of research has tested strategies aimed at encouraging patients to be screened in accordance with recommended guidelines (e.g., Masi, Blackman, & Peek, 2007xClose
Masi, C.M., Blackman, D.J., & Peek, M.E. (2007). Interventions to enhance breast cancer screening, diagnosis, and treatment among racial and ethnic minority women. Medical Care Research and Review, 64, 195S-242S.). Although increased screening is not universally recommended, efforts to promote screening are common – including, but not limited to, screening for breast, cervical, ovarian, colorectal, and prostate cancers. Self-report validity studies often report kappa (i.e., percent agreement), sensitivity (i.e., true positives—the proportion of participants screened according to objective markers who self-reported the screening), and specificity (i.e., true negatives—the proportion of participants not screened according to objective markers who self-reported no-screening). Concordance rates for medical records and self-reported data indicate that the prevalence of cancer screening is overestimated by self-report (Gordon, Hiatt, & Lampert, 1993xClose
Gordon, N.P., Hiatt, R.A., & Lampert, D.I. (1993). Concordance of self-reported data and medical record audit for six cancer screening procedures. Journal of the National Cancer Institute, 85(7), 566-570.; Hiatt et al., 1995xClose
Hiatt, R.A., Perez-Stable, E.J., Quesenberry, Jr., C., Sabogal, F., Otero-Sabogal, R., & McPhee, S.J. (1995). Agreement between self-reported early cancer detection practices and medical audits among Hispanic and non-Hispanic white health plan members in North Carolina. Preventive Medicine, 24, 278-285.), whereas the time since the most recent test is underestimated (Gordon et al., 1993xClose
Gordon, N.P., Hiatt, R.A., & Lampert, D.I. (1993). Concordance of self-reported data and medical record audit for six cancer screening procedures. Journal of the National Cancer Institute, 85(7), 566-570.). Research in other areas has found that people can often accurately report the day of week a given event occurred, yet they tend to report a more recent date than actually was the case (Cohen & Java, 1995xClose
Cohen, G., & Java, R. (1995). Memory for medical history: Accuracy of recall. Applied Cognitive Psychology, 9, 273-288.; Thompson, Skowronski, & Lee, 1988xClose
Thompson, C.P., Skowronski, J.J., & Lee, D.J. (1988). Telescoping in dating naturally occurring events. Memory and Cognition, 16, 461-468.). This may occur because greater clarity of a memory provokes feelings of recency (Bradburn et al., 1987xClose
Bradburn, N.M., Rips, L.J., & Shevell, S.K. (1987). Answering autobiographical questions: The impact of memory and inference on surveys. Science, 236, 157-161.). Along these lines, people tend to anchor their reports to reasonable timeframes and/or round the values off to the number of weeks or months (Huttenlocher et al., 1990xClose
Huttenlocher, J., Hedges, L.V., & Bradburn, N.M. (1990). Reports of elapsed time: Bounding and rounding processes in estimation. Journal of Experimental Psychology: Learning, Memory, and Cognition, 16(2), 196-213.). Each of these lines of evidence suggests that report of specific dates or the duration of time passed since an event may be inaccurate. The sources of these biases are unclear, but they likely reflect individuals’ reliance on schemas when answering temporally-based questions.

Overall, research suggests that patient self-reports of cancer screening are reasonably valid. However, the precision of estimates of timing are considerably less reliable (e.g., specific dates or the time since the most recent screening). It is important to note, however, that patient reports are not always intentionally biased. For example, several types of screening can be conducted as part of a full examination, leaving patients unaware that a particular test was conducted (Hall et al., 2004xClose
Hall, H.I., Van Den Eeden, S.K., Tolsma, D.D., Rardin, K., Thompson, T., Sinclair, A.H., et al. (2004). Testing for prostate and colorectal cancer: comparison of self-report and medical record audit. Preventive Medicine, 39, 27-35.).

Self-reports of cancer risk behaviors. Cancer risk is elevated by the presence of both uncontrollable and controllable risk factors. Self-reports are used to estimate the prevalence of risk factors in the population and the efficacy of interventions seeking to reduce them. Risk factors that are beyond one’s control generally include family history/genetics, race/ethnicity, prior history of cancer, and age. However, there are a number of controllable risk factors that are related to behavior, such as smoking, heavy alcohol use, poor diet/nutrition, physical inactivity, ultraviolet light exposure, and risky sexual behavior. A complete review of the nature of self-reports of these factors is beyond the scope of this discussion; rather, our aim is to consider several key variables related to cancer risk, and to briefly describe evidence for the validity of their self-report. Newell and colleagues (1999)xClose
Newell, S.A., Girgis, A., Sanson-Fisher, R., & Savolainen, N.J. (1999). The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: A critical review. American Journal of Preventive Medicine, 17(3), 211-229. conducted a comprehensive review of the accuracy of self-reported health behaviors and cancer-related risk factors. They found that, in general, self-reports consistently underestimated risk factor prevalence and percentages of ‘at-risk’ individuals.

Heavy alcohol use is associated with elevated cancer risk (Cargiulo, 2007xClose
Cargiulo, T. (2007). Understanding the health impact of alcohol dependence. American Journal of Health-System Pharmacy, 64(5), S5-S11.). The gold standard for biochemical verification of short-term alcohol use is a breathalyzer test; yet this test is infrequently used in research (see Newell et al., 1999xClose
Newell, S.A., Girgis, A., Sanson-Fisher, R., & Savolainen, N.J. (1999). The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: A critical review. American Journal of Preventive Medicine, 17(3), 211-229.). Grønbaek and Heitmann (1996)xClose
Grønbaek, M., & Heitmann, B.L. (1996). Validity of self-reported intakes of wine, beer, and spirits in population studies. European Journal of Clinical Nutrition, 50(7), 487-490. found overall agreement between self-reports on an alcohol use frequency questionnaire and dietary interviews. However, the number of studies that carefully examine the validity of self-report of alcohol use is not yet adequate to form firm conclusions. Even in the absence of biochemical verification, the "bogus pipeline" (a procedure that induces the [false] belief that drinking will be biochemically verified; e.g., Botvin, Botvin, Renick, Filazzola, & Allegrante, 1984xClose
Botvin, E.M., Botvin, G.J., Renick, N.L., Filazzola, A.D., & Allegrante, J.P. (1984). Adolescents’ self-reports of tobacco, alcohol, and marijuana use: Examining the comparability of video tape, cartoon and verbal bogus-pipeline procedures. Psychological Reports, 55, 379-386.; Campanelli, Dielman, & Shope, 1987xClose
Campanelli, P.C., Dielman, T.E., & Shope, J.T. (1987). Validity of adolescents’ self-reports of alcohol use and misuse using a bogus pipeline procedure. Adolescence, 22, 7-22.; Jones & Sigall, 1971xClose
Jones, E.E., & Sigall, H. (1971). The bogus pipeline: A new paradigm for measuring affect and attitude. Psychological Bulletin, 76, 349-364.) can increase the accuracy of self-reports of alcohol consumption in clinical or research settings.

Physical activity levels are also commonly estimated in cancer prevention studies. Reporting levels of physical activity is challenging for several reasons. Respondents are asked to recall many separate events over a period of time, some of which may not be particularly salient or memorable (e.g., walking). Recall is also more difficult when respondents report both duration and intensity of each activity. In addition, the categories of physical activities defined in surveys (e.g., the Seven Day Activity Recall questionnaire; Sallis, Buono, Roby, Micale & Nelson, 1993xClose
Sallis, J.F., Buono, M.J., Roby, J.J., Micale, F.G., & Nelson, J.A. (1993) Seven-day recall and other physical activity self-reports in children and adolescents. Medicine and Science in Sport and Exercise, 25, 99-108.) require respondents to make judgments about what constitutes moderate, hard, and very hard activities. Sallis and colleagues (1993)xClose
Sallis, J.F., Buono, M.J., Roby, J.J., Micale, F.G., & Nelson, J.A. (1993) Seven-day recall and other physical activity self-reports in children and adolescents. Medicine and Science in Sport and Exercise, 25, 99-108. found lower reliability for repeated reports from longer intervals (4–6 days between interviews) versus shorter intervals, suggesting rapid decay of subjects’ ability to remember specific physical activities.